Treatment of mediastinitis in children after cardiac surgery. A study of 20 cases.

Twenty-three cases of mediastinitis after cardiac surgery in children were treated by us between 1973 and 1976. Three patients died within 6 hours of admission. Treatment used in the tweny other cases are discussed. The mean age of the patients was three years and three months. The mediastinitis was evident an average of twelve days after extracoporeal circulation. A staphylococus was always responsible for the infection. Treatment was a combination of surgery, antibiotics and respiratory and nutritional supplies. The surgical treatment consisted of a careful mediastinal cleansing with resection of the sternal edges. In fifteen patients the thorax was closed after surgery, and an irrigation system installed using a solution of 4% Dakin in physiologic saline. Recovery was simple in 5 patients. In the 10 other patients of this group the thorax had to be reopened; one patient died after 90 days from Serratia marcescens endocarditis. The thorax was left open initially in five patients: one patient of this group died from candida endocarditis. All patients needed endotracheal ventilation through a nasotracheal tube (7 to 90 days of ventilation). Treatment with bactericidal antibiotics was pursued for three months and a monotherapy was kept for nine months. After reviewing the observed complications, our methods and results are compared with others in the literature.

[Dysautonomia in acute primary polyradiculoneuritis]. / La dysautonomie des polyradiculonévrites aiguës primitives

In this research involving 172 cases of acute primary polyradiculoneuritis, the authors draw attention to the frequency and seriousness of the autonomic disorders, notably circulatory disorders (arterial hypertension, bradycardia), water retention, disorders in glucose metabolism. They have found a close correlation between the development of arterial hypertension and levels of VMA and the cathecholamines and between the appearance of hyperglycaemia and the level of urinary 17 OH. Free water clearance is often negative and becomes positive as the paralytic syndrome improves. The biological picture is identical with that brought about by inappropriate secretion of HAD. From the therapeutic point of view, caution is advised in using certain procedures and in prescribing certain drugs.

[Methyl bromide poisoning. 3 cases, 1 fatal. Neruopathological study of one case of coma with myoclonus followed for 5 years]. / Intoxication par le bromure de méthyle Trois observations, dont une mortelle Etude neuro-pathologique d'un cas de stupeur avec myoclonies, suivi pendant cinq ans

Three new cases of methyl bromide poisoning (leakage from a fire extinguisher) are reported. Two of these were characterized, after an initial period of coma and myoclonic status, by an action myoclonus. Electrical data are presented. A follow up of 4 and 8 years allowed to study the effect of drugs, two of which (clonazepam and baclofene) being pecularly contributive. The third patient outlived for 5 years in a stuporous state with myoclonus. The anatomical findings consisted mainly of a necrosis of both inferior colliculi with gliosis in the upper brain stem reticular formation and moderate changes in the dentate and pontine nuclei. Their significance is discussed in view of physiological and experimental knowledge.

[An Acinetobacter baumanii outbreak at the Versailles Hospital Center]. / Investigation d'une épidémie à Acinetobacter baumannii au Centre Hospitalier de Versailles.

A. baumannii is a multiresistant bacteria which is recognised as responsible for nosocomial infections and hospital outbreaks. The control of these outbreaks depends on the strain's typing and on the fight's policy against nosocomial infections. An outbreak of A. baumannii is occurred to patients who were hospitalized in Centre Hospitalier de Versailles. To investigate this outbreak, we have determined the biotype (Bouvet's method), the succeptibility pattern (disk diffusion and agar dilution results were analysed with the hierarchical classification and main component analysis) and the total DNA macrorestriction pattern (Pulse Field Gel Electrophoresis using SmaI restriction enzyme). A risk factors for A. baumannii acquisition were delineated in case-control study. During 2 years, 38 patients have been infected or colonized to A. baumannii. Thirty two patients were hospitalized in ICU. We studied 38 non repetitive clinical isolates and 9 strains of the patient's rooms. Four biotypes were defined by the Bouvet's typing method. Fourteen groups were obtained when succeptibility results were analysed with the hierarchical classification and 6 with the main composant analysis. The molecular typing permit us to define 4 epidemic and 6 sporadic strains. All the epidemic strains were isolated on ICU hospitalized patients. Our study has shown wide contamination in patient's rooms (Water tap, dry surfaces, patient's mattresses...). Environmental objects have been a major risk factor for A. baumannii acquisition. The control of this outbreak has been possible by application of hygienic measures (hands washing, isolment, meticulous cleaning of the ICU and environmental controls). No new case is occurred in the last year. Typing methods and case-control study are necessary to investigate cross-infections and take efficient measures against these outbreaks.

[Changes in anti-tetanus antibodies under sero-toxoid therapy. Study in 50 patients with tetanus]. / Evolution sours sero-anatoxinothérapie des anticorps anti-tétaniques. Etude chez 50 tétaniques

A study concerning changes in anti-tetanus antibody (ATA) levels in 50 patients with tetanus following the injection of antitetanic serum of equine origin and of toxoid, the first dose of the latter being given 24 hours after the administration of serum and the others at intervals of 5 to 7, 15 and 30 days. Repeated estimation of ATA demonstrated, regardless of the toxoid dose protocol adopted, that levels did not reach 0.1 IU/ml on the 30th day and that they only rose late. By contrast, after a booster, the increase was the same as that seen in subjects who had not acquired tetanus. The various factors which may underly defective active immunisation during the acute phase of tetanus are discussed. Heterologue serum therapy, which has been held responsible, cannot be considered to be a responsible factor since patients who did not receive serum behaved in exactly the same way as those who had. By virtue of this "gap" in the acquisition of immunity, the use of heterologue serum is recommended to neutralise any remaining circulating toxin as rapidly as possible.

[Brucella osteitis in children]. / Ostéite à brucelles chez l'enfant.

The authors report a case presenting with a very rare localization of brucellosis: the isolated involvement of a single bone of the metatarsus, in a child in otherwise excellent general condition. The lesions of the diaphysis and epiphyses induced a fragility of the epiphyseal cartilage and a minimal traumatism resulted in a detachment of the epiphysis which was the first clinical sign. The bacteriological examination of a sample of pus led to the early diagnosis of brucellosis, therefore allowing efficient treatment.

Pharmacokinetics of ranitidine in acute upper gastrointestinal haemorrhage.

A pharmacokinetic study of ranitidine was performed in 14 patients with haematemesis divided into two groups according to the severity of blood loss. Pharmacokinetic values were calculated from plasma concentrations after the first of three daily injections (100 mg) and compared with those obtained in five healthy volunteers (50 mg i.v.). There were no significant differences between patients in the two haemorrhage groups and controls. The low, or even questionable, effectiveness of histamine H2-receptor antagonists in the treatment of upper gastrointestinal haemorrhage does not seem to be due to pharmacokinetic factors.

Comparison of high-performance liquid chromatography and polyclonal fluorescence polarization immunoassay for the monitoring of midazolam in the plasma of intensive care unit patients.

Midazolam (M) is used as an induction agent for anesthesia. The main metabolite is alpha-hydroxymidazolam (OM), which is pharmacologically active. Use of M for sedation is a recent application, rapidly gaining favor. Monitoring of the level of sedation is fundamental in that an excessive and prolonged effect is associated with the risk of complications. Thus, it was felt both necessary and useful to measure circulating M levels. We compared a high-performance liquid chromatography (HPLC) assay with fluorescence polarization immunoassay (FPIA) for the measurement of M in the serum of 138 sedated patients in the intensive care unit (i.e., 179 samples). Response of the OM was also assessed. The degree of crossover of the metabolite was between 76.8 and 32.7%. The equation of the regression line for sigma HPLC (i.e., the sum M + OM) versus FPIA was TDx = 1.1585 sigma HPLC + 143.42 (R = 0.966). The 95% confidence interval for the slope was 1.1551, 1.1619. The regression slope differed significantly from 1 (p < 0.001) and shows that FPIA measurements overestimated concentrations obtained by HPLC on the order of 19%. The discrepancy between the two techniques was all the more notable when concentrations were > 1,000 ng/ml. The relative selectivity of Abbott industrial reagent in terms of benzodiazepines leads to the identification of what might be called a midazolam-like (M-like) activity covering both M and OM. The development of a global FPIA method for measurement of this M-like activity in sedated patients provides a satisfactory solution to the question raised.